Review of Health Economics of Point-of-Care Testing Worldwide and Its Efficacy of Implementation in the Primary Health Care Setting in Remote Australia

Regulation and governance for the implementation and management of point-of-care testing in Australia: a scoping review

BACKGROUND

Point-of-care testing (PoCT) is an increasingly important diagnostic tool in the healthcare system for accessible pathology testing in hospital, primary care, and community care settings. Clear regulation and governance models are important to ensure quality of PoCT results for patient care.

METHODS

This review aimed to identify existing regulation and guidelines for management of PoCT and how this has been implemented within Australian healthcare services. We conducted a search of academic publications in PubMed and grey literature (national, state, and independent organisations) and other publicly available information from internet searches for governance of PoCT in Australia. Relevant data from these sources were extracted and narratively synthesised.

RESULTS

Forty-seven sources (17 studies from PubMed, 30 grey literature) were included in the final review. Of the grey literature sources, fifteen current PoCT governance documents comprising of six standards, five guidelines and four frameworks at the international, national and jurisdictional level were included with an increasing number of grey literature sources since the onset of the COVID-19 pandemic in 2020. The seventeen included research articles were categorised according to implementation barriers and facilitators with the themes of workforce, clinical governance, PoCT workflow, and cost. An understanding of the clinical and cultural context for PoCT was the most frequently reported facilitator of PoCT, while the most frequently reported barrier was related to inadequate data management.

CONCLUSION

This review demonstrated limited and inconsistent sources on regulatory and governance models for implementing and managing PoCT in Australia. Identified PoCT programs showcased diverse implementation and governance models to support quality PoCT, with few reporting formal accreditation. Streamlined, practical regulation and governance for PoCT may increase adoption across healthcare settings while ensuring quality results and meeting the needs of patients and healthcare practitioners.

Tracking the Risk of Cardiovascular Disease after Almond and Oat Milk Intervene or Statin Medication with a Powerful Reflex SH-SAW POCT Platform

Cardiovascular disease (CVD) represents the leading cause of death worldwide. For individuals at elevated risk for cardiovascular disease, early detection and monitoring of lipid status is imperative. The majority of lipid measurements conducted in hospital settings employ optical detection, which necessitates the use of relatively large-sized detection machines. It is, therefore, necessary to develop point-of-care testing (POCT) for lipoprotein in order to monitor CVD. To enhance the management and surveillance of CVD, this study sought to develop a POCT approach for apolipoprotein B (ApoB) utilizing a shear horizontal surface acoustic wave (SH-SAW) platform to assess the risk of heart disease. The platform employs a reflective SH-SAW sensor to reduce the sensor size and enhance the phase-shifted signals. In this study, the platform was utilized to monitor the impact of a weekly almond and oat milk or statins intervention on alterations in CVD risk. The SH-SAW ApoB test exhibited a linear range of 0 to 212 mg/dL, and a coefficient correlation (R) of 0.9912. Following a four-week intervention period, both the almond and oat milk intervention (-23.3%, p < 0.05) and statin treatment (-53.1%, p < 0.01) were observed to significantly reduce ApoB levels. These findings suggest that the SH-SAW POCT device may prove a valuable tool for monitoring CVD risk, particularly during routine daily or weekly follow-up visits.

The experiences and perspectives of people with gout on urate self-monitoring

INTRODUCTION

Gout management remains suboptimal despite safe and effective urate-lowering therapy. Self-monitoring of urate may improve gout management, however, the acceptability of urate self-monitoring by people with gout is unknown. The aim of this study was to explore the experiences of urate self-monitoring in people with gout.

METHODS

Semistructured interviews were conducted with people taking urate-lowering therapy (N = 30) in a 12-month trial of urate self-monitoring in rural and urban Australia. Interviews covered the experience of monitoring and its effect on gout self-management. Deidentified transcripts were analysed thematically.

RESULTS

Participants valued the ability to self-monitor and gain more understanding of urate control compared with the annual monitoring ordered by their doctors. Participants indicated that self-monitoring at home was easy, convenient and informed gout self-management behaviours such as dietary modifications, hydration, exercise and medication routines. Many participants self-monitored to understand urate concentration changes in response to feeling a gout flare was imminent or whether their behaviours, for example, alcohol intake, increased the risk of a gout flare. Urate concentrations were shared with doctors mainly when they were above target to seek management support, and this led to allopurinol dose increases in some cases.

CONCLUSION

Urate self-monitoring was viewed by people with gout as convenient and useful for independent management of gout. They believed self-monitoring achieved better gout control with a less restricted lifestyle. Urate data was shared with doctors at the patient's discretion and helped inform clinical decisions, such as allopurinol dose changes. Further research on implementing urate self-monitoring in routine care would enable an evaluation of its impact on medication adherence and clinical outcomes, as well as inform gout management guidelines.

PATIENT OR PUBLIC CONTRIBUTION

One person with gout, who was not a participant, was involved in the study design by providing feedback and pilot testing the semistructured interview guide. In response to their feedback, subsequent modifications to the interview guide were made to improve the understandability of the questions from a patient perspective. No additional questions were suggested.

Antenatal ultrasound needs-analysis survey of Australian rural/remote healthcare clinicians: recommendations for improved service quality and access

BACKGROUND

Ultrasound is the primary diagnostic tool in pregnancy, capable of identifying high-risk pregnancies and life-threatening conditions, allowing for appropriate management to prevent maternal and fetal morbidity and mortality. Women and babies from rural and remote Australia and low-resource areas worldwide experience poorer health outcomes and barriers to accessing antenatal care and imaging services. Healthcare clinicians working in these regions face significant challenges practising with limited resources and accessing training opportunities.

OBJECTIVE

To perform an exploratory needs-analysis survey investigating the availability, accessibility and use of antenatal ultrasound in rural Australia, exploring rural clinicians' interest in and access to ultrasound training opportunities.

METHODS

The survey tool for this cross-sectional study was designed and distributed as an anonymous online questionnaire targeting healthcare clinicians (doctors, nurses, midwives, clinic managers, Aboriginal healthcare workers) providing antenatal care in rural regions. Descriptive analysis was applied to quantitative data and thematic analysis was used to explore qualitative components.

RESULTS

A total of 114 valid survey responses were analysed. Overall, 39% (43/111) reported ultrasound was not used when providing antenatal care to patients at their clinic, stating 'Lack of ultrasound equipment (73%,29/40) and inaccessibility of training opportunities (47%,19/40) as the main reasons. For those with ultrasound (61%,68/111), estimating due date (89%,57/64) was the main use, and limited training/skills to operate the equipment (59%,38/64) and inaccessibility/distance of training opportunities (45%,29/64) were the most commonly reported barriers. Clinicians described a lack of childcare options (73%,74/102), long distances to reach ultrasound services (64%,65/102), appointment (59%,60/102) and transport availability/times (46%,47/102) as the main obstacles to patient access. Increased attendance, compliance with care directives, parental bonding and improved lifestyle choices were described by respondents as positive outcomes of antenatal ultrasound use.

CONCLUSIONS

Future efforts to combat inequitable service access must adopt a coordinated approach to meet the needs of pregnant women in low-resource settings. Providing portable ultrasound equipment, training in antenatal Point-of-Care ultrasound (PoCUS) with ongoing support/mentoring and accreditation of health professionals could strengthen rural workforce capacity. This, along with addressing the complex economic, environmental and socio-cultural barriers faced by patients, could improve service access and pregnancy outcomes in rural and remote communities.

Performance Evaluation of AFIAS ST2 and Ichroma ST2 Assays in Comparison with Presage ST2 Assay

Background

Elevated soluble suppression of tumorigenicity 2 (sST2) levels may predict mortality in heart failure (HF) patients. The AFIAS ST2 assay (AFIAS ST2, Boditech Med Inc., Chuncheon, Korea) and ichroma ST2 assay (ichroma ST2, Boditech Med Inc.) are newly developed point-of-care (POC) assays for measuring sST2 level. We evaluated the performance of these assays, in terms of cut-off validation and prognosis, and compared them with that of the Presage ST2 assay (Presage ST2, Critical Diagnostics, San Diego, CA, USA).

Methods

We validated the US FDA-claimed sST2 clinical cut-off of 35 ng/mL using 420 serum samples (298 samples from the universal sample bank of the American Association for Clinical Chemistry and 122 samples from reference individuals from Konkuk University Medical Center). We compared AFIAS ST2 and ichroma ST2 with Presage ST2, using 206 samples from patients with HF. We assessed prognosis using the three assays in 252 samples from the Barcelona ambulatory HF cohort subsets.

Results

The upper reference limits of AFIAS ST2 and ichroma ST2 were within the clinical cut-off of Presage ST2. The results of AFIAS ST2 and ichroma ST2 were highly correlated with those of Presage ST2 (r = 0.82 and 0.81, respectively). Based on this cut-off, all three assays predicted cardiovascular death.

Conclusions

The new POC assays, AFIAS ST2 and ichroma ST2, would be useful in clinical practice for managing HF patients, with performances equivalent to that of Presage ST2.

Advanced Lab-on-Fiber Optrodes Assisted by Oriented Antibody Immobilization Strategy

Lab-on-fiber (LoF) optrodes offer several advantages over conventional techniques for point-of-care platforms aimed at real-time and label-free detection of clinically relevant biomarkers. Moreover, the easy integration of LoF platforms in medical needles, catheters, and nano endoscopes offer unique potentials for in vivo biopsies and tumor microenvironment assessment. The main barrier to translating the vision close to reality is the need to further lower the final limit of detection of developed optrodes. For immune-biosensing purposes, the assay sensitivity significantly relies on the capability to correctly immobilize the capture antibody in terms of uniform coverage and correct orientation of the bioreceptor, especially when very low detection limits are requested as in the case of cancer diagnostics. Here, we investigated the possibility to improve the immobilization strategies through the use of hinge carbohydrates by involving homemade antibodies that demonstrated a significantly improved recognition of the antigen with ultra-low detection limits. In order to create an effective pipeline for the improvement of biofunctionalization protocols to be used in connection with LoF platforms, we first optimized the protocol using a microfluidic surface plasmon resonance (mSPR) device and then transferred the optimized strategy onto LoF platforms selected for the final validation. Here, we selected two different LoF platforms: a biolayer interferometry (BLI)-based device (commercially available) and a homemade advanced LoF biosensor based on optical fiber meta-tips (OFMTs). As a clinically relevant scenario, here we focused our attention on a promising serological biomarker, Cripto-1, for its ability to promote tumorigenesis in breast and liver cancer. Currently, Cripto-1 detection relies on laborious and time-consuming immunoassays. The reported results demonstrated that the proposed approach based on oriented antibody immobilization was able to significantly improve Cripto-1 detection with a 10-fold enhancement versus the random approach. More interestingly, by using the oriented antibody immobilization strategy, the OFMTs-based platform was able to reveal Cripto-1 at a concentration of 0.05 nM, exhibiting detection capabilities much higher (by a factor of 250) than those provided by the commercial LoF platform based on BLI and similar to the ones shown by the commercial and well-established bench-top mSPR Biacore 8K system. Therefore, our work opened new avenues into the development of high-sensitivity LoF biosensors for the detection of clinically relevant biomarkers in the sub-ng/mL range.

Oral glucose tolerance test to diagnose gestational diabetes mellitus: Impact of variations in specimen handling

To improve birth outcomes, all pregnant women without known diabetes are recommended for an oral glucose tolerance test (OGTT) to screen for hyperglycaemia in pregnancy (diabetes in pregnancy or gestational diabetes mellitus (GDM)). This narrative review presents contemporary approaches to minimise preanalytical glycolysis in OGTT samples with a focus on GDM diagnosis using criteria derived from the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study. The challenges of implementing each approach across a diverse Australian healthcare setting were explored. Many Australian sites currently collect and transport OGTT samples at ambient temperature in sodium fluoride (NaF) tubes which is likely to lead to missed diagnosis of GDM in a significant proportion of cases. Alternative preanalytical solutions should be pragmatic and tailored to individual settings and as close as possible to the preanalytical conditions of the HAPO study for correct interpretation of OGTT results. Rapid centrifugation of barrier tubes to separate plasma could be suitable in urban settings provided time to centrifugation is strictly controlled. Tubes containing NaF and citrate could be useful for remote or resource poor settings with long delays to analysis but the impact on the interpretation of OGTT results should be carefully considered. Testing venous blood glucose at the point-of-care bypasses the need for glycolytic inhibition but requires careful selection of devices with robust analytical performance. Studies to evaluate the potential error of each solution compared to the HAPO protocol are required to assess the magnitude of misdiagnosis and inform clinicians regarding the potential impact on patient safety and healthcare costs.

Roadmap for large-scale implementation of point-of-care testing in primary care in Central and Eastern European countries: the Hungarian experience

Objective:

The aim of this study is to give a broad overview of the international best practices regarding the implementation of point-of-care testing (POCT) in primary care (PC) setting and to highlight the facilitators and barriers for widespread national uptake. The study focuses on the managerial and organizational side of POCT, offering a roadmap for implementation as well as highlighting the most important requirements needed to unlock the clinical and economical potential of POCT in the Hungarian healthcare system.

Methods:

We conducted an English language scoping literature review between January 2012 and June 2021 to assess the recent trends of POCT implementation in developed countries. Our research focuses on the recent publications of several European and Anglo-Saxon countries where POCT utilization is common. In parallel, we reviewed the Hungarian regulatory framework, ongoing governmental legislation, and strategies influencing the POCT dissemination in the Hungarian PC sector.

Results:

Among the possible POCT usage in PC, we identified several clinically relevant devices and tests (C-reactive protein, urine, blood glucose, D-dimer, prothrombin time) important in screening and early detection of morbidities representing high disease burden. Based on international literature, general practitioners (GPs) are interested in the shortened diagnostic times, portable devices, and better doctor–patient relations made possible by POCT. There are several concerns, however, regarding initial and operational costs and reimbursement, limited scientific evidence about quality and safety, unclear regulations on quality validation of tests, as well as managerial aspects like PC staff training and IT integration at the GP level.

Conclusion:

As our review highlights, there is considerable interest among GPs to implement POCT as it has the potential to improve quality of care; however, there are many obstacles to overcome before widespread uptake. Further investigation is recommended to elaborate management and quality insurance background and to develop appropriate regulatory framework and financial scheme for GP practices. Preferably this work should involve the local practicing GPs to better tailor the implementation roadmap to country-specific details.

Point-of-care testing in a high-income country paediatric emergency department: a qualitative study in Sweden

OBJECTIVES

In many resource-limited health systems, point-of-care tests (POCTs) are the only means for clinical patient sample analyses. However, the speed and simplicity of POCTs also makes their use appealing to clinicians in high-income countries (HICs), despite greater laboratory accessibility. Although also part of the clinical routine in HICs, clinician perceptions of the utility of POCTs are relatively unknown in such settings as compared with others. In a Swedish paediatric emergency department (PED) where POCT use is routine, we aimed to characterise healthcare providers' perspectives on the clinical utility of POCTs and explore their implementation in the local setting; to discuss and compare such perspectives, to those reported in other settings; and finally, to gather requests for ideal novel POCTs.

DESIGN

Qualitative focus group discussions study. A data-driven content analysis approach was used for analysis.

SETTING

The PED of a secondary paediatric hospital in Stockholm, Sweden.

PARTICIPANTS

Twenty-four healthcare providers clinically active at the PED were enrolled in six focus groups.

RESULTS

A range of POCTs was routinely used. The emerging theme Utility of our POCT use is double-edged illustrated the perceived utility of POCTs. While POCT services were considered to have clinical and social value, the local routine for their use was named to distract clinicians from the care for patients. Requests were made for ideal POCTs and their implementation.

CONCLUSION

Despite their clinical integration, deficient implementation routines limit the benefits of POCT services to this well-resourced paediatric clinic. As such deficiencies are shared with other settings, it is suggested that some characteristics of POCTs and of their utility are less related to resource level and more to policy deficiency. To address this, we propose the appointment of skilled laboratory personnel as ambassadors to hospital clinics offering POCT services, to ensure higher utility of such services.

Leading POCT Networks: Operating POCT Programs Across Multiple Sites Involving Vast Geographical Areas and Rural Communities

Few peer-reviewed publications provide laboratory leaders with useful strategies on which to develop and implement point of care testing (POCT) programs to support delivery of acute care services to remote rural communities, with or without trained laboratory staff on site. This mini review discusses common challenges faced by laboratory leaders poised to implement and operate POCT programs at multiple remote and rural sites. It identifies areas for consideration during the initial program planning phases and provides areas for focus during evaluation and for continued improvement of POCT services at remote locations. Finally, it discusses a potential oversight framework for governance and leadership of multisite POCT programs servicing remote and rural communities.

Point-of-Care Haematology Analyser Quality Assurance Programme: a rural nursing perspective

BACKGROUND AND CONTEXT Rural health services without an onsite laboratory lack timely access to haematology results. Set in New Zealand's far north, this paper provides a rural nursing perspective on how a health service remote from a laboratory introduced a haematology analyser suitable for point-of-care use and established the associated quality assurance programme. ASSESSMENT OF PROBLEM Five broad areas were identified that could impact on successful implementation of the haematology analyser: quality control, staff training, physical resources, costs, and human resource requirements. RESULTS Quality control testing, staff training and operating the haematology analyser was more time intensive than anticipated. Finding adequate physical space for placement and operation of the analyser was challenging and costs per patient tests were higher than predicted due to low volumes of testing. STRATEGIES FOR IMPROVEMENT Through a collaborative team approach, a modified quality assurance programme was agreed on with the supplier and regional point-of-care testing co-ordinator, resulting in a reduced cost per test. The supplier provided dedicated hours of staff training. Allocated time was assigned to run point-of-care testing quality assurance. LESSONS Having access to laboratory tests can reduce inequalities for rural patients, but natural enthusiasm to introduce new point-of-care technologies and devices needs to be tempered by a thorough consideration of the realities on the ground. Quality assurance programmes need to fit the locality while being overseen and supported by laboratory staff knowledgeable in point-of-care testing requirements. Associated costs need to be sustainable in both human and physical resources.